20100006004 CASE PRESENTATION
LONG CASE
57 M came to casualty with c/o generalised weakness since 1 month ,fever since 1 week,altered sensorium since 3 days.
A 39 year old male presented with chief complaints of
shortness of breath since since 6 months
Generalised body swelling since 6 months
Decreased urine output since 6 months.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 and half years back ,
then the patient had an episode of giddiness ?due to shock (from the death of his brother in law) ,for which he went to a local hospital and got diagnosed with hypertension.
Since then the patient was started on increasing doses of Telma and later Telma -H, but the patient was not compliant to the medication. He used to take the medication only when there's occasional neck stiffness and pain.
History of mild shortness of breath and chest pain 2 years back, which is not associated with cough or fatigue for which he went to a local hospital where he was told to have uncontrolled blood pressure and patient was started on cilnidipine.
Since then complaints were decreased in frequency but did not subsided.
Shortness of breath worsened 18 months back from exertion to even at less than ordinary activity ( NYHA Grade 2 to 3 which is associated with bilateral pedal edema, pitting type, upto the knees.
H/o fever 16 months back, associated with cough and weight loss (patient's waist size reduces from 32 to 28 in the span of 1 month) relieved with medication sputum was negative for cbnaat.
In February 2022 patient presented to our hospital with complaints of worsened shortness of breath even at rest, Diagnosed to have Acute pulmonary edema secondary to heart failure and Renal Failure and treated conservatively with Diuretics and Anti hypertensives. Symptoms relieved and patient discharged with online follow up.
8 months back in view of refractory pulmonary edema and metabolic acidosis patient was initiated on hemodialysis and continuing maintainance hemodialysis regularly with frequency of 2-3 times per week.
Current admission :
Patient presented with Shortness of breath at rest and intermittent generalised body swelling and distension of abdomen since 6 months
Fever since 1 month
Shorteness of breath initially on exertion which gradually worsened to shortness of breath at rest associated with distension of abdomen.
Fever which is high grade, intermittent type associated with chills not associated with nausea, vomiting, altrered sensorium, cough and burning micturation.
personal psychosocial history:-
37 yrs old male elder son of his family who studied till 9th standard later he discontinued because of financial issues there after he started his own business at the age of 12yrs( paper recycling) runned for about 3yrs and discontinued because of loss in his business and returned to his grown up place there after for about 1-2yrs he went for farming with his parents and later because in need of more money he started working as lorry cleaner( as he do overnight work and feel tired he started getting habituated to drink alcohol and smoking)in the gap of 2 yrs he learned how to drive and he continued as lorry driver( he returns to home once in a week, used to continuously drink alcohol more than a full bottle with dec intake of food, in between a week too she used to drink).After 8yrs (2014) he got married later after this children were born he discontinued as lorry driver and started working as daily labourer where he used to lift heavy weights after doing work to overcome his tiredness he used to drink alcohol (180ml/day). one fine day (in the year of 2020) he went to his sister house(family gathering),there was an incident of sudden death of his brother in law he became very anxious( as his sister lost his husband in young age) and weak when he got his first bp check ( 190/110) he was prescribed anti htn but he refused to take it regularly( as there is a misnom in his village not to take antihtn in a very young age) and to overcome his sorrowness he started taking much more alcohol and smoking very regularly.
All his present complaints started since the month of November (2021) where he first noticed pedal edema and sob on exertion
Psychological illness in current admission :
Since 6 months patient has family disputes with wife and mother in regards to his health, addictions ( tobacoo chewing )
4 months back in a huge argument among the couple , his wife left him alone and reached her maternal home along with there children. Since then he couldn't sleep at night even he doesnt feel breathless.
On further enquiry He emotionally broke down and remembered sleepless nights he spent in memories of his children. Since then he was emotionally upset which hampered self care and stopped taking Tab. Telma 40 mg and Met XL 50 mg ( both due to ignorance and financial issues ). Increased water intake with altrered food habbits.
Problems to be addressed
1. Depression
2. Tobacco deaddiction
PAST HISTORY:
No similar complaints in the past.
No significant medical or surgical history
Not a known case of DM, bronchial asthma, CAD, Epilepsy
FAMILY HISTORY:
No family history of HTN, DM, bronchial asthma, epilepsy
PERSONAL HISTORY :
Sleep disturbances since 6 months
Appetite improved since dialysis but decreased since distension of abdomen
Decreased urine output and no constipation.
Patient is a chronic alcoholic and chronic smoker since 15 years
Alcohol 90-150 ml per day whiskey/brandy
1-2 beedi per day for 15 years
Tobacco chewing daily Since 15 years
Examination :
Patient is conscious, coherent, cooperative well oriented to time place and person.
Thin built and moderately nourished.
Vitals :
Bp 140/70 mmhg
HR 110 bpm
Temp 103.5F
RR 24-26 cpm
Positive findings :
General examination
Temporal wasting
Prominent superficial temporal vessels
Pallor
Dry and Bald tounge
Mild Pectus excavatum ( false finding may be due to grossly distended abdomen )
Bilateral pedal edema
Systemic examination :
Cardiovascular system :
Raised JVP seen above the angle of mandible in sitting position
Diffuse visible precordial pulsations
Diffuse Apex beat with lateral most palpable at left 6th intercostal space lateral to mid clavicular line
Parasternal heave present
Palpable P2 present
Pansystolic murmur present best heard at apex and radiating to left axilla
Grade 4/6
Per Abd examination :
Grossly distended abdomen
Fullness of flanks
Umbilicus everted
Subcutaneous soft swellings consistent with lipoma
Tenderness present at needle insertion site ( last paracentesis 3 days back )
No organomegaly
Fluid thrill present
Respiratory system :
Bilateral air entry present, crepitations in bilateral infra axillary area.
Central nervous system :
No focal neurological deficits.
INVESTIGATIONS :
Hemogram :
Haemoglobin: 5.1gm/dl
Total count:6,200 cells/cu mm
Neutrophils: 80
Lymphocytes: 10
Eosinophils:02
Monocytes:08
Basophils:00
PCV:16.1
MCV:85.2
MCH:26.9
MCHC:31.6
RDW CV:15.6
RDW SD:47.7
RBC count:1.89
Platelet count: 1.2 lakh
RBC:microcytic hypochromic few pencil cells
WBC:within normal limits
Platelets:count decrease on smear
No hemo parasites seen
Impression: microcytic hypochromic anemia with thrombocytopenia
2D Echo
Right atrium dilated,Right ventricle dilated,left atrium dilated,left ventricle dilated,concentric LVH+
ESD:4.74
EDD:6.58
DPW:1.38
EF:52%
FS:26%
IVS:1.38
Aorta:3.85
Pulmonary artery:Dilated
Pericardium:minimal PE(+)
IVS size(2.27cms)
Mitral flow:E>A
Aortic flow:1.69
Pulmonary flow:1.10
Tricuspid valve:Rvsp=70+10=80mmhg
Severe TR with PAH:moderate to severe AR/MR
Global hypokinesia,no as/ms
Fair LV function
No diastolic dysfunction,no LV clot
RFT :
Urea:72
Creatinine:7.3
Uric acid:6.0
Calcium:9.6
Phosphorus: 4.4
Sodium:143
Potassium: 4.3
Chloride: 101
LFT :
Total Bilirubin:0.87
Direct Bilirubin:0.17
SGOT:17
SGPT:20
Alkaline phosphate:132
Total proteins:6.0
Albumin:2.7
A/G Ratio:0.85
USG Abdomen :
Liver- Normal size and echogenic
Spleen-10cm Normal size and echogenic
Rt kidney-7.5×3.1cm
Lt Kidney-7.6×3.2cm
CMD lost
U.bladder minimally distended
No lymphadenopathy
Gross Ascites
Impression:B/L Grade 2-3 RPD changes
Gross Ascitis
Serum iron:79
RBS:85
Ascitic fluid Analysis :
Sugar:104
Protein:3.0
Ascitic Fluid Amylase:36.1
Ascitic fluid for ldh:110
SAAG
Serum Albumin:2.7
Ascitic Albumin:1.54
SAAG:1.75
LDH:215.7
HIV1/2 Rapid test Non reactive
HBsAg-RAPID is Negative
Anti HCV Antibodies :Non reactive
Problem representation
39M with Chronic kidney disease with Heart failure and pyrexia.
Problems to be tackled
Ascites
Shortness of breath
Fever
Anasarca
----------------------------------------------------------------------------------------------------------------------------------------
SHORT CASE II
A 60 year old male, ambulance driver by occupation & resident of appalguda thanda of suryapet district presented to OPD with chief complaints of
Chief complaints :
Red coloured urine since 2 months
Shortness of breath since 45 days
Generalised weakness since 30 days
Constipation since 6 days
HOPI :
Patient was apparently asymptomatic 2 months back. Then he noticed red coloured urine, which was insidious in onset, gradually progressive. Increased in frequency of urine, mainly during night time.
Incontinuity of urine is present, at first patient passes red colour urine for few seconds followed by decreased urinary stream associated with sensation of obstruction and pain, after intense pressure he passes dark coloured clots and then normal stream of red coloured urine.
He also has burning micturition and supra-pubic pain while passing urine.
Patient also has compliants of constipation since 6 days which resolves on taking medication.
H/o giddiness.
H/o tremors .
No H/O fever, weightloss
No H/O loss of appetite
No H/O cough and hemoptysis
No H/O nausea,vomiting,loose stools.
No H/o orthopnea and paroxysmal nocturnal dyspnea.
No H/O abdominal distension, abdominal pain.
Past History:
History of hydrocele, since 15 years.
He worked as a driver for 20 years.
History of trauma 15 years back, while lifting the lorry back door, he slipped and fell during this.
After this incident in 1-2 months he noticed a swelling in the right groin which is gradually increased in size, painless. Later he neglected the swelling as there was no pain.
Not a k/c/o HTN, diabetes, asthma, epilepsy, TB.
No H/O any past surgery.
He has a H/O fracture of left humerus at distal end, when he was 20 years old, while cutting a tree. Then he got treated for it with reduction and plaster of Paris. But the treatment resulted in maluni7on.
Personal History:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder: constipation since 6 days
Addictions:
Alcohol intake every day (90ml) from 30 years, stopped 2 months back.
Smoking daily 20 beedi in 1 day from 30 years,stopped 2 months back
Family history:
No significant history.
General examination:
Patient is conscious, coherent, and co-operative. Well oriented to time place and person.
He is moderately built and moderately nourished.
Pallor- present
Icterus- absent
Cyanosis- absent
Clubbing- absent
No lymphadenopathy
No edema
Vitals :
Temperature- Afebrile
Blood pressure- 120/80mm hg
Pulse rate- 96bpm
Respiratory rate- 20cpm
Systemic examination:
Per abdomen:
On inspection:
Shape of abdomen: scaphoid
Umbilicus: inverted
Movements of abdominal wall with respiration
Scars present( due to beliefs that it helps in digestion, done in childhood)
Swelling in scrotum.(hydrocele?)
No visible peristalsis, pulsations, sinuses, engorged veins.
On palpation:
All Inspection findings are confirmed
No local rise of temperature
Soft and non tender
No palpable masses
Liver is not palpable
Spleen is not palpable
On percussion:
Tympanic note present
On auscultation:
bowels sounds heard
CVS examination:
Inspection:
No raised JVP
Trachea appears to be central
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Palpation:
Trachea central in position
Apex beat is felt in the fifth intercostal space, 1cm medial to the midclavicular line
Auscultation:
S1 S2 heard
No murmurs
Respiratory examination:
Shape of chest is elliptical, bilaterally symmetrical
B/L airway entry present
Normal vesicular breath sounds
CNS Examination:
Conscious, coherent, cooperative and well oriented
Normal speech.
No neurological deficit found.
DIAGNOSIS:
Severe Anemia secondary to blood loss (Hematuria)
? Urothelial malignancy with right sided vaginal hydrocele .
Comments
Post a Comment